National Défense Defence nationale

ISSUE 3, 2015

DOSSIER Use It or Lose It CHECK SIX Canada’s Aviation Medicine Pioneers – Part 2 VIEWS ON FLIGHT SAFETY Commander of the Royal Canadian Air Force Cover – A Royal Canadian Air Force technician guides a CP-140 Aurora to its parking area during Operation IMPACT in Kuwait on February 5, 2015.

Use It or Lose It 23 Photo: DND Photo:

Expanding Flight Safety... 29

Sleeping At The Wheel 30

Crossing Over 31

Dude Where’s My Jet? 35

Short on Time 36

Use It or Lose It 23 TABLE OF CONTENTS Issue 3, 2015 Regular Columns Views on Flight Safety 4 The Editor’s Corner 5 For Professionalism 6 Maintenance in Focus 10 Check Six 12 On Track 18 From the Investigator 37 Epilogue 40 The Back Page – Directorate of Flight Safety (Ottawa) & 1 Canadian Air Division Flight Safety (Winnipeg) Organizational Chart 42

Dossiers Risk Understanding and Management in the Establishment of a New Capability 20 Use It or Lose It 23 Expanding Flight Safety South of the Equator 29

Lessons Learned Sleeping at the Wheel 30 Crossing Over 31 The Holes Align 33 Dude Where’s My Jet? 35 Short on Time 36

DIRECTORATE OF THE CANADIAN ARMED Send submissions to: To contact DFS personnel on FLIGHT SAFETY FORCES FLIGHT SAFETY an URGENT flight safety issue, MAGAZINE National Defence Headquarters please call an investigator who is Director of Flight Safety Directorate of Flight Safety available 24 hours a day at Colonel Steve Charpentier Flight Comment is produced up to four times Attn: Editor, Flight Comment (DFS 3-3) 1-888-927-6337 (WARN-DFS). a year by the Directorate of Flight Safety. 101 Colonel By Drive Editor The contents do not necessarily reflect Ottawa, ON, Canada, K1A 0K2 Visit the DFS web page at Major Peter Butzphal official policy and, unless otherwise stated, www.rcaf-arc.forces.gc.ca/en/flight-safety. Assistant Editor should not be construed as regulations, Telephone: 613-992‑0198 Aviator Amélie Labrie orders or directives. Contributions, comments FAX: 613-992‑5187 and criticism are welcome. Contributions Email: [email protected] Imagery Technician become the property of Flight Comment and Corporal Daisy Hiebert may be edited for content, length or format. This publication or its contents Graphics and design may not be reproduced without d2k Marketing Communications the editor’s approval. ISSN 0015‑3702 A‑JS‑000‑006/JP‑000 Views on Flight Safety by LGen M.J. Hood, Commander of the Royal Canadian Air Force Photo: Cpl Heather Tiffney Heather Cpl Photo:

ome safety thoughts from the Commander to execute our diverse air power functions risk management principles. This is where the of the Royal Canadian Air Force... (whatever your trade) within the rules and raison d’être of Flight Safety comes into play, regulations established through our rich whereby we employ effective risk management S You might not realize how long the history. To this end, while we recognize that strategies to accomplish the mission at the Canadian Armed Forces’ (CAF) Flight Safety humans can occasionally make mistakes, we lowest level of risk practicable. Safety risks program has been in existence. The foundations do not culturally accept purposeful violations must be assessed then articulated to the chain of the program were first introduced during the of our rules, regulations, and procedures. of command to ensure that latent or residual latter stage of the Second World War at a time This is the foundation of our effective ‘just risk is accepted at the appropriate level. when it was assessed that we were losing too culture’ system. many Royal Canadian Air Force (RCAF) assets Further, we should avoid allowing ourselves to (aircraft and people) in accidents that were The statistical database of our Flight Safety drift unwittingly into a higher risk regime. For preventable and not directly attributable to program demonstrates clearly that the highest any airpower operation risk awareness is key; enemy action. Of course it has evolved over the proportion of our safety incidents, we must always assess risks, mitigate them last 73 years,1 but the fact that the program is notwithstanding the advances in aviation as much as possible, refer higher risk up the chain still functioning well today is testament to its technology, are either attributable to human as necessary, to ensure we make risk-aware importance and success. error directly or as a consequence of a human decisions to execute action when the factors causal linkage. While humans in the mission demands. These risk concepts are Why is this relevant? We need to remember loop represent our greatest strength, as a relevant for all Canadian air power missions, that many of our contemporary Standing consequence of our susceptibility to errors, training or operational. Operating Procedures and training techniques slips and lapses, we also naturally draw have been borne out of costly lessons learned concomitant risk—a risk that is always Statistically, we have had the lowest number of through the safety incidents of our air power prevalent and should drive us to maintain catastrophic accidents for some time, and while forbears. This lengthy period of commitment an ever-vigilant approach to human factors we should be justifiably proud of our to the safety review, learn, and improve cycle is consideration across all our air power operations. commitment to safety, we must guard against fundamentally important as it provides the safe complacency. Our Flight Safety program is operational platform from which we execute Another important flight safety principle second to none, but the positive statistics and training and operational missions today. is force preservation. Some might suggest that data are irrelevant if we do not maintain an force preservation and mission execution ongoing commitment to accident prevention. Out of great respect for the airmen and represent almost naturally opposing functions, Do not believe in our Flight Safety program airwomen that went before us, and as a but I do not support this view. Force preservation as a consequence of positive statistics; the well-established Air Force, we always need and mission execution are linked by effective integrity of the program is only as good as

4 Flight Comment — Issue 3, 2015 the commitment of all members of the team Remember that Flight Safety is everyone’s to the Flight Safety culture. The RCAF responsibility but, first and foremost, it is a airworthiness and safety philosophy demands leadership responsibility. that all understand their role to be vigilant, speak up loudly and confidently, stand by the rules and Reference regulations, and work to effectively manage risks. 1. The first known formal recognition of the need for a dedicated Flight Safety Organization I am fully committed to a healthy and robust occurred in mid-1942 when the RCAF Aircraft Flight Safety program for the CAF, and I expect Accident Investigation Board (AIB) was formed Commanders at all levels to assume a forceful under a Chief Inspector of Aircraft Accidents. cultural role in our program. It is essential that our aircrew, our maintainers, as well as our support trades, actively participate in the program so that we are able to deliver Canadian air power safely and effectively.

Editor’sThe Corner

elcome back! I hope you had a fun the ever-increasing use of systems guidance fighters/ trainers, fixed-wing, rotary wing and and enjoyable summer. within the training syllabus and the difficulty maintenance sections. Readers can check out W for most students to appropriately navigate the “Back Page” to see just who they are. It is that time once again whereby we when said guidance (read: GPS) did not function welcome to the position a new Commander of correctly. Please have a read. I would enjoy Finally, as a reminder to those who could find the Royal Canadian Air Force and invite him to hearing any of your comments or anecdotes on themselves dealing with a Flight Safety share his thoughts on and vision for the Canadian the matter. In addition, Part 2 of “Canada’s occurrence investigation, if you need guidance Armed Forces’ (CAF) Flight Safety (FS) program. Aviation Medicine Pioneers” continues in this and/ or you want to get a second opinion on your As the General mentions in “Views on Flight issue with the development of pressure suits, initial investigation plan, you ALWAYS have Safety”, we within the CAF find ourselves helmets and oxygen masks. 24/7 access to the duty DFS investigator at [fortunately] in a lull regarding catastrophic 1-888-WARN-DFS (927-6337) for advice. That’s accidents but nevertheless must be on top of our On another note, it is also that time of year when part of the duty DFS investigator’s role. game in the fight against complacency that can the Director of Flight Safety soon begins his tour easily set in. Of greater note is his remark that FS is of military units and civilian contractors across the Volare tute everybody’s responsibility however; the onus is on country. In October, the Director will start off this Major Peter Butzphal the leadership to forcefully instill the culture season’s journey in Halifax/ Shearwater. Check throughout all levels of command. with your FS representative for the tentative dates at your unit. In this issue, we borrow an interesting article from a study recently completed in the United States With the passing of another posting season on the loss of proficiency in pilot cognitive skills comes the arrival of new members to the due to the extensive use of automation in flying. Directorate of Flight Safety (DFS). I would like to I found this article quite relevant, case in point take the opportunity to welcome those who just having witnessed as a Qualified Flight Instructor, checked-in on the investigative side within the

Issue 3, 2015 — FlightFlight CommentComment 5 Professionalism For For commendable performance in flight safety

Major Anthony Ambrosini n 20 November 2013, Maj Anthony Ambrosini, analysis discovered that the breather valve Maj Ambrosini is commended for his astute a CH146 Griffon First Officer with within the oil cap had deteriorated over time and observation and highly professional conduct. O 400 Tactical Helicopter Squadron, was ceased to function. As a result, the breather valve The loss of lubrication oil in the 90 degree tasked to carry out a pilot proficiency training mission. over-pressurized the system and oil blew out gearbox could easily have been missed due to of the valve leaving little oil in the gearbox. staining of the oil level sight glass. His decision to Prior the mission, other members of the crew The stain on the sight glass led others to believe have a crewmember inspect the gearbox averted had completed a walk around. The Aircraft that there was oil in the 90 degree gearbox. a potentially disastrous situation and he is most Captain also performed another brief walk around deserving of the For Professionalism Award. and signed out the aircraft. While embarking on the aircraft, Maj Ambrosini took it upon himself to perform yet another walk around despite the fact that this was not a normal requirement in the performance of his duties. He noticed the oil level in the 90 degree gearbox at the lower portion of the sight glass seemed stained and it was difficult to determine if the stained portion of the sight glass was oil. The other crewmembers believed that there was sufficient oil in the 90 degree gearbox. Despite this, Maj Ambrosini instructed one member to obtain a ladder so that the oil level could in fact be confirmed. This subsequent inspection revealed that there was indeed no oil in the 90 degree gearbox. Later maintenance Photo: DND Photo:

Master Corporal Martin Léveillé n 17 January 2014, MCpl Léveillé, an Recognizing the possibility that this problem avionics instructor at Canadian Forces might not be limited to this specific type of tool, O School of Aerospace Technology and MCpl Léveillé took the initiative and carried out a Engineering (CFSATE) was carrying out his monthly further investigation that determined that out of inspections of the tool boards used during practical 28 tools of this brand at the unit, 18 had springs exercises by students. He astutely observed that missing. Due to the potential seriousness of his a spring was missing on a set of diagonal cutters findings, foreign object damage (FOD) checks and immediately informed the unit tool control were immediately carried out on all CFSATE coordinator of his findings. aircraft. With his knowledge that this brand of

Continued on next page Photo: Sgt Christopher Sgt Bentley Photo: 6 Flight Comment — Issue 3, 2015 Master Corporal Miguel Lourenco n 16 July 2012, while performing a the Canadian Forces Technical Orders, pre-flight inspection of a CH146 Griffon, this stopper serves to dampen sudden O MCpl Lourenco, a 430 Tactical Helicopter backward movement of a cargo door and Squadron Flight Engineer, discovered that the prevents the door from completely number one engine tachometer cannon plug departing the aircraft in flight. was broken and there were exposed electrical wires. He also observed that the right-side cargo MCpl Lourenco’s outstanding attention door was improperly installed. to detail while performing a pre-flight inspection of the cockpit instruments and The number one engine tachometer is located cargo door assembly clearly averted a on the cockpit center instrument panel and the serious occurrence. MCpl Lourenco’s broken cannon plug to this gauge is only visible professional efforts make him deserving with significant effort. MCpl Lourenco’s superior of this For Professionalism Award. attention to detail clearly averted the potential for loss of vital number one engine performance information. He also found the right-side cargo door was improperly installed as a critical stopper in the sliding cargo door was placed 90 degrees opposite to the axis of a normal installation. When installed in accordance with Photo: DND Photo:

Master Corporal Martin Léveillé ...Continued tool is prevalent Forces wide, he quickly realized MCpl Léveillé’s actions clearly demonstrated the mitigation process which has resulted in changes this was a wide-spread hazard and informed the importance of tool control and its implications to the tool control program at CFSATE and as Wing Flight Safety team. MCpl Léveillé’s findings with respect to flight safety, particularly to the such, he is truly deserving of this For resulted in a Flight Safety Hazard Report and a impressionable aircraft maintenance technician Professionalism Award. Flight Safety Flash being raised to bring this incident students at CFSATE. His attention to detail and to the attention of all aircraft maintenance his initiative to investigate on his own showed a operational units across the Royal Canadian Air very high level of professionalism. In addition, Force, highlighting the potential FOD danger to MCpl Léveillé was involved in the follow up error all flying assets.

Issue 3, 2015 — Flight Comment 7 Professionalism For For commendable performance in flight safety

Corporal Jeremy Pagé n 8 July 2014, while conducting a pre-flight reach the primary structure of the aircraft. If this inspection on a CH146 Griffon helicopter, delamination had continued without anyone O Cpl Pagé, an Aviation Technician with noticing, a serious accident might have occurred. 430 Tactical Helicopter Squadron, noticed an The outstanding attention to detail displayed by anomaly on the tail boom on the co-pilot’s side Cpl Pagé during the inspection of an assembly of the aircraft. Knowing that the tail was that generally undergoes a pre-flight visual constructed of composite materials, he conducted inspection was instrumental in preventing a a tactile inspection of this part in addition to the potential catastrophic failure of the tail boom. visual inspection, as the latter would not have Cpl Pagé is unquestionably deserving of the allowed him to identify any defects. Since this For Professionalism Award for his efforts. inspection went far beyond the periodic visual inspections, Cpl Pagé called on the services of an Aircraft Structures Technician, whose inspection revealed a partial delamination of an area measuring 30 by 45 centimetres on the tail boom. Cpl Pagé removed the helicopter from

service to ensure that the delamination did not DND Photo:

Corporal Pierre-Luc Tremblay n 23 January 2014, Cpl Tremblay, an Going beyond the requirements of the maintenance aviation technician with 425 Tactical orders, he carried out an in-depth inspection of O Fighter Squadron, was deployed on the door and discovered that one of the remaining exercise CANNONBALL at Marine Corps Air bolts had broken in two. Cpl Tremblay immediately Station Miramar in San Diego, California. While reported this unusual occurrence to the Flight performing a post-flight inspection of the Safety section of 1 Canadian Air Division. right-hand main landing gear of a CF188 Hornet, A non-destructive testing inspection was then he observed a missing bolt on the door hinge. initiated to determine the extent of the damage to the landing gear door. Stress-related Continued on next page Photo: LS Alex Roy

8 Flight Comment — Issue 3, 2015 Corporal Jocelyn Boudrias n 19 June 2014, Cpl Jocelyn Boudrias, the tower regarding whether or not the Cormorant an Air Traffic Controller trainee had been cleared the option to land for this O at 19 Wing Comox, observed a circuit. Following the second simulated tail rotor CH149 Cormorant helicopter on the far end of the malfunction, the Cormorant landed at the same runway from which a commercial aircraft departure end of the runway, un-noticed by the was about to takeoff. He instantly informed the tower. The controller then proceeded to give a primary Controller who immediately cancelled the departure clearance to a commercial aircraft on commercial aircraft’s takeoff clearance, just the same runway. before they began their takeoff roll. Cpl Boudrias occupied the very busy and workload The Cormorant was conducting a training intensive Tower Data position. This position is exercise and had requested the entire length of administrative and generally personnel who are the runway to complete a simulated tail rotor assigned to it are not trained to understand the malfunction, normally flown to not below ten complexities of Air Traffic Control (ATC). Despite feet above the runway. At the time, the traffic Cpl Boudrias’ lack of ATC training, his vigilance, pattern in Comox was quite busy and tower was situational awareness, quick thinking and rapid adjusting traffic flow to accommodate the intervention were directly responsible in Cormorant. The first attempt at the simulated averting a serious incident. Had he not spoken DND Photo: tail rotor malfunction, for which the Cormorant up, a clear potential for a departure collision had been cleared the option to land, was cut would have existed. Cpl Boudrias’ exceptional short due to commercial traffic. The Cormorant diligence and decisive actions are commendable and was then re-cleared into the circuit for another fully deserving of this For Professionalism Award. simulated tail rotor malfunction. There was a misunderstanding between the Cormorant and

Corporal Pierre-Luc Tremblay ...Continued delamination and multiple cracks were identified. during the installation of the new door drawn He clearly displayed notable airmanship and is As a result of this inspection, the door had to be from supply, he verified the attaching hardware to be commended for his superior efforts by replaced and the damaged door was quarantined supplied with the door assembly. The supplied awarding him the For Professionalism Award. for further investigation. bolts were also made up of the wrong material. These observations were relayed to the Life Cycle Cpl Tremblay was instrumental in the undertaking Material Manager who initiated a fleet-wide of a local inspection on the nine remaining jets special inspection. deployed on this exercise to determine if incorrect bolts had also been installed on these Cpl Tremblay’s attention to detail averted the aircraft. A total of four aircraft were identified potential for a landing gear door departing in with the wrong hardware installed. Furthermore, flight and causing damage to the aircraft.

Issue 3, 2015 — Flight Comment 9 Maintenance INFOCUS

PARTS HANDLING – AIRWORTHINESS APPLICABLE? by WO James Gilmour, DGAEPM (TA&S) 6-4-3-4, DND Technical Inspector, Bell Helicopter Textron Canada

s technicians, most of us have aspects of aircraft maintenance. When Additional costs in repairing components opened a container or package from receiving a part from supply, it will arrive damaged in shipping consume funds that A the supply system only to discover a in a proper container with adequate would otherwise be utilized for overhauling problem with the component or that some protection (bubble wrap, foam, etc.). The other parts. Each fleet has a certain amount of the airworthiness paperwork missing. U/S component should be returned through of funding for the fiscal year for Repair and This of course raises red flags in our minds supply in the same condition and preferably Overhaul. Say for example, an engine oil that this is not how it should be. The problem in the same container the replacement part filter costs $1,000, the cost for overhaul would is normally brought to the attention of the arrived in. This will ensure that the component be a few hundred dollars, if you include the supply tech or to our supervisor, depending is well protected passing through the supply cost of shipping. If the filter was damaged on where you opened the box. Phone calls chain, until it arrives at contractor for repair. are made and emails are sent in order to try to rectify the problem before sending the part back. Hopefully, the solution is relatively simple and aircraft maintenance can continue. If not, then a replacement part is obtained. When returning a part for repair, it would be expected that care is still given to the component. While the component may be unserviceable (U/S) due to a failure or it is Photo: DND Photo: time expired, we must ensure that it is still treated as an aircraft part. Proper handling of these components is crucial through all Improper sized packaging

10 Flight Comment — Issue 3, 2015 Incorrect packing of helicopter Section of firewall folded in half then main rotor blade Correct packing of rotor blade Condition tags missing placed in box Photo: DND Photo:

Electrical connection missing connector hardware Rotor head assembly attaching hardware Contents of boxes found in main rotor Helicopter rotor head assembly in crate in engine compressor section. Engine potentially without condition tags. As such, parts cannot head assembly crate with no condition tag, packed with other boxes contaminated with foreign object debris be tracked and are therefore unusable

beyond repair in shipping, it will now cost $1,000 Senior technicians have a responsibility to teach to purchase a replacement. Proper packaging would ‘‘While the component the new technicians on all aspects of aircraft have prevented the damage and the component may be unserviceable (U/S) due maintenance, including parts return. The procedure would be put back into service following overhaul. to a failure or it is time expired, for returning a part ensures that all appropriate Cost saving would be roughly $800, which would we must ensure that it is still treated airworthiness and supply documentation is kept essentially pay for another four overhauls. While as an aircraft part.’’ with the component. Protecting it so that it this may seem like a trivial amount, numerous survives the shipping process should be everyone’s components with additional damage will add up responsibility. While each fleet has AF9000 over the course of a year. processes to be followed with regards to parts The result is cannibalizing pieces from one handling, experience and knowledge is still the component to repair another one. While not the As fleets get older and technology changes, some ultimate teaching tool. Pass on your knowledge. components become more and more difficult to best solution, this procedure allows us to keep repair. The inner workings of a gauge for example, spare parts in the system. If parts are damaged may not be repairable due to outdated technology. during shipping, we could lose the ability to salvage these parts.

Issue 3, 2015 — Flight Comment 11 PART 2 Canada’s Aviation Medicine Pioneers

By Lydia Dotto Reproduced and modified with permission from the Canadian Space Agency

Pressure Suits The G-suit dealt with only one of the physiological • Hypoxia: a decrease of oxygen in the blood • Armstrong’s line: the altitude (roughly challenges faced by pilots flying high-performance caused by reduced atmospheric pressure. 60,000 feet) at which water goes from a aircraft. As planes flew higher and higher, crews Hypoxia can affect vision, cause dizziness and liquid to a gas (i.e. boils) at body temperature. also had to be protected against the drop in reduce muscle coordination. Without an Exposure above this altitude can cause atmospheric pressure with altitude. Early military oxygen supply, pilots can lose consciousness unconsciousness and death in seconds. aircraft were not pressurized at all and were limited in less than a minute after exposure to low in how high they could fly without endangering the pressures at high altitudes. In the 1950s, after graduating from the crew. Aircraft that were pressurized to maintain a • Decompression sickness, also known as University of Western Ontario with a degree safe level of internal pressure could fly much “the bends”: joint pain caused by nitrogen in math and physics, Roy Stubbs worked on higher—but crews were still at risk if there was bubbling out the blood and tissues as a result developing pressure suits for pilots who would a sudden loss of pressure (known as explosive of a rapid decrease in atmospheric pressure. be flying new Canadian fighter aircraft such decompression) or when bailing out at Severe cases can result in death. as the Avro CF-100 Canuck and the soon-to-be- high altitudes. There are two kinds of pressure suits: partial pressure suits and full pressure suits. The former do not cover the entire body and contain inflatable tubes that apply pressure to the chest area, as well as the arms and legs. Above about 50,000 feet, pilots require a completely sealed full-body pressure suit equipped with an oxygen breathing system. These suits protect against several physiological risks associated with high-altitude flying, including: Photo: CSA Photo:

A photo of some of the early models of the pressure suit

12 Flight Comment — Issue 3, 2015 infamous Avro Arrow, which were then in Since both the G-suit and the pressure vest were After testing the ventilated suit in a wooden development. These aircraft did not require the made of rubber, aircrew wearing the suits ran mock-up of the aircraft using heat lamps to use of full pressure suits because they were used the risk of suffering heat stress in flight. “The simulate high-heat conditions, Soper was ready for fairly short-duration missions, unlike body loses a lot of heat by evaporative cooling. to try it in the Arrow itself. The test never bombers that flew missions lasting many hours. If you put on an impermeable suit, you can’t lose happened. “I was supposed to fly in theArrow What was required, said Stubbs, were “get-you- heat by the evaporation of moisture,” said the day it was cancelled,” he said. down suits” that could protect the pilot in the Douglas Soper, who worked on the design and event of an explosive decompression while he testing of a ventilation system for the suit. Like everyone else associated with the project, brought the plane to a lower altitude. “Fighter he was shocked and disappointed by the news. or interceptor aircraft usually operated near The overheating resulted not only from the However, he didn’t have much time to brood base, unlike the bombers, so the suits got you pilot’s metabolism and exertions but also from about it because he was scheduled to go to the down from altitude safely to return home if aerodynamic heating of the skin of the aircraft, Royal Air Force Institute of Aviation Medicine in cabin pressure was lost,” Stubbs said. (Bombers, which was radiated into the cabin. (Astronauts Farnborough, England, to continue work on which ranged much further afield, couldn’t inside the space shuttle face a similar phenomenon air-cooled garments. “The British were very simply descend a safer altitude because this during re-entry into the earth’s atmosphere, interested in what we had been doing with the would increase fuel consumption, making it which is why the shuttle is coated underneath Arrow and they picked my brain. They were more difficult to get home.) with heat-resistant tiles.) building the TRS-2, a big fighter aircraft that had a lot of similar features. They were particularly In the fighters, it was sufficient to wear a One of the options for ventilating the suits was interested in the design of our cockpit AC outlets pressure vest and anti-G suit that could be to create a garment threaded with small tubes because if large quantities of air are blown out of inflated differentially if the aircraft lost pressure filled with cooling water, a design that is an orifice, a very noisy whistling condition results or created G forces. To accomplish this, Stubbs employed today in the suits used by astronauts which they were having trouble solving.” developed a pressure-gravity valve that was for spacewalks. However, in Soper’s day, they fitted to the pressure vest and went down to the decided this was too complicated and instead In 1959, Soper went to Farnborough, where he G-suit. If the pilot experienced G forces, only developed a system that drew air from the spent more than two years engaged in several the G-suit inflated. If cabin pressure was lost, aircraft’s air conditioning system. This resulted research projects. His interest in how the body both the G-suit and the pressure vest were inflated in a tug-of-war with the engineers responsible loses heat led him into some interesting and a pressure oxygen mask was activated. for the Arrow’s cooling system. adventures. For example, he studied professional fishmongers who worked on the docks cutting Stubbs said the development of the partial The Arrow “was a very demanding aircraft in up cod fish off the fishing ships. The fish were pressure suit was one important reason why the many ways,” said Soper. “We hadn’t got to the kept in ice to preserve them and the fishmongers design of the Franks G-suit was switched from sophisticated electronics we have today; we had were continually plunging their hands into icy water to air. Both would be needed for the the old-fashioned radio tubes. They not only seawater. “They were very skilled men. They Arrow, which was being developed at the time. used a lot of electricity, they produced a lot of were filleting the fish with razor sharp knives— The scientists at the Institute of Aviation heat. Every time I thought I had enough AC [for it was like skilled surgery with ice-cold hands. Medicine (IAM) and its successor organizations ventilating the suit], the electronic engineers They were so cold that if they missed with the “were very much involved in developing would have to have some more cooling for the knife and cut their hands, they wouldn’t even equipment for it. We fitted out the test pilots electronics bay and they would take it away from know it until they saw them bleeding. with these suit systems so when they flew the the cockpit and its occupants. It became quite a I wondered, how could they do this?” Arrow, they had protection.” back-and-forth struggle.” Continued on next page

Issue 3, 2015 — Flight Comment 13 Many people tried the job because it paid well, This system allowed his body temperature to Between 1954 and 1956, Roy Stubbs also worked but most gave it up in short order because they continue climbing into an artificial fever situation. at Farnborough on the development of full-body couldn’t stand the cold. “Some could only stand “You would get very hot,” he said. In fact, he pressure suits. These suits were not being it once, some for a week. But some of them could sometimes went into convulsions due to developed in Canada at the time because Canada do it all the time,” said Soper. “They were a hyperventilation. The people who were monitoring was not flying long-range bombers on which unique set of people that had unique blood flow the experiment couldn’t see him inside the tin can, they would be needed. Some of the bombers through the hands.” but they were alerted to the convulsions when the could fly above 50,000 feet and the flights could balance arm on which the bed was resting last for many hours, so the crews needed At the other end of the temperature scale, Soper started to shake. “They’d put my head in a paper protection from getting the bends in the event of subjected himself to sweltering conditions to bag so that I could re-breathe my own respiratory cabin depressurization. “The bomber crews were gain insight into the mechanisms of body heat carbon dioxide and in a couple of minutes the normally far from base, so they had to stay at loss and the conditions that induce heat stress. convulsions from the hyperventilation would stop.” altitude to have enough range to continue on the “We were trying to understand what mission, or to get home if cabin pressure goes on in a cockpit when people get failed,” Stubbs said. overheated,” he said. “Heat stress can be fatal very quickly.” He recalled an The British were flying bombers, so Stubbs incident in which two U.S. pilots were was seconded to Farnborough to help flying long distances over tropical waters develop a full pressure suit there. As its wearing rubber suits to protect them if name suggests, and unlike the partial they went down at sea. “One guy got pressure suit, the full pressure suit covers into real trouble from heat stress. He was the entire body, including the hands and flying so erratically at the end that it feet, and also requires the use of a was obvious he was going to crash. pressure helmet. The entire unit must You could hear the two pilots on the be completely sealed. intercom, hollering, pull up, pull up. Too late, too late.” One of the things Stubbs examined was the suit’s comfort factor. “We had done In extreme heat conditions, Soper said, testing in altitude chambers, so we knew “you reach a point where you can’t lose the suit would protect us. What we had to heat, you can only gain heat. You can’t find out was whether it was a practical lose heat from conduction or convection thing to wear. Could you fly in it? Was it if the air around you is hotter; you can’t too cumbersome?” lose heat by evaporative cooling if the air is saturated.” Like Soper, he was also interested in heat stress. Wearing the suit was like wearing a Soper during one of his pressures experiments That’s exactly the state he found himself rubber glove all over the body and it could in during tests at Farnborough. He lay on be “pretty miserable,” he said. It had to be a bed on top of a large balance arm ventilated even while the aircrew was inside a compartment that he described as walking to board the plane. “a big tin can.” The temperature and For relief, he would sometimes slip outside the Particularly concerned about the use of the suit humidity were maintained at a level that building into the cool morning air. “I was stark in tropical climates, Stubbs and his colleagues made it impossible for his body to lose heat. naked and I would go out and lean against the tested it in a bomber flying out of Khartoum, The subject had to remain motionless during wall—it was the quickest way to cool off. One Sudan. It was so hot that the plane couldn’t take the heat exposure so that the beam balance day, I was leaning against the wall with my eyes off during the day because its jet engines needed could measure the amount of sweat that closed when I heard a female voice saying, ‘Good cooler air; in fact, it could barely taxi. dripped off his body. The exposures were morning, Flight Lieutenant.’ I don’t think I was about one hour long. even interested in replying, I was so hot.”

14 Flight Comment — Issue 3, 2015 Stubbs noted that these tests demonstrated Another result of the tests, he said, was the that ventilation suits were needed even on realization that “more development work was the ground, as temperatures could reach necessary to improve our full pressure helmets.” nearly 60˚C. He added that the plane was always welcomed by ground crews at the bases it visited because, after flying at 52,000 feet, it was nicely chilled. “They wanted to climb inside a cold airplane, so we got great treatment.”

Helmets and Oxygen Masks Pressure suits were of little use without proper helmet maker in the United States at the time, helmets and oxygen masks and the Institute of and they built a model that was put through Aviation Medicine (IAM) scientists invested a lot extensive trials at IAM. of effort in improving both. As head of the Flying Personnel Medical Establishment, Roy Stubbs felt Stubbs devised a way to test the helmet designs there was an urgent need for a new helmet design for slipstream tolerance in the decompression that would protect aircrew during ejections from chamber—although not with human subjects high-speed aircraft. One of the major goals was this time. (“There were limits,” said Douglas to design a helmet and mask that would stay on Soper.) The window of the chamber was the pilot’s head during an ejection or a crash. removed and replaced with a stovepipe that “The crash hats we were using would not stay on acted as an air funnel. Then a dummy’s head your head when you crashed— they were wearing the helmet being tested was placed in always coming off,” said Soper, who headed the front of the stovepipe. With just a thin piece of team that tested the new design from 1961 to craft paper covering the stovepipe hole, the pressure 1967 after returning from Farnborough. in the chamber was reduced to the desired altitude. “When you cut the paper, the air would rush in The helmets were also vulnerable to being with an instantaneous pulse,” said Soper. whipped off by the plane’s slipstream when a crewmember ejected. When that happened, he This work resulted in the development of “the also lost his oxygen mask and communications first helmet that would stay on your head in an system. Stubbs developed on a new helmet accident,” he said. It was used by the Royal design that would ensure the pilot would keep Canadian Air Force for many years. the oxygen mask during the ejection process. Of course, the oxygen systems associated with “We had to design it as a two-piece unit and that the helmets were also critically important. In his had never been done before. You put it on as a CAHS paper, Peter Allen notes that “in 1939, the CSA Photo: one-piece unit, but if the wind force was too oxygen masks used by the British, American and high, the outer shell would just break off. Canadian air services were sadly inadequate. An early model of an oxygen mask to be used with a pressure suit It disconnected, but left the mask on.” He took They were extremely wasteful of oxygen and the idea to Gentex, a company that was the top many a mission had to be completed after the

Continued on next page

Issue 3, 2015 — Flight Comment 15 supply had been used up.” He said that Canadian- The standard oxygen mask used at the time, you were swallowing at that point, your lungs developed pressure vests and oxygen masks known as the Pate suspension mask, was not could burst. We always made a point of making allowed Allied pilots to fly 2,000 to 5,000 feet adequate to deliver oxygen under pressure, said sure the mouth was open at the time we pulled higher than enemy pilots. “This was a closely Soper. It had straps strung through rollers that the plug.” guarded secret which the enemy did not know were used to pull the mask tight to the face but about until after the war.” An “ingenious” valve they did not provide a strong enough seal for Typically, Bryan and Leach were their own guinea in the oxygen mask that assisted pilots in positive pressure breathing. “Even when you pigs. “If you’re going to do experimental work, breathing out against the mask’s pressure turned up the tension to counter the oxygen you should do it first on yourself,” Bryan said. allowed “our reconnaissance aircraft to operate pressure, you got a lot of leaking.” The new “My work was to sit in the chamber at 8,000 feet above the ceiling of enemy fighters, enabling British helmet, on the other hand, “had a visor and get blasted to 40,000 feet.” He added wryly: them to perform essential tactical photography built into it and you could get a lot of pressure “I had to persuade several of my friends to do the while escaping unscathed.” Researchers at the built up with this thing.” same thing—that’s why I have so few friends.” Clinical Investigation Unit (CIU) were also the Soper served as a test subject for some of these first to develop an oxygen mask that did not The reason Canada was interested in this helmet was—again—the Arrow, which could fly up to experiments and he had an unexpected and freeze up at high altitudes. The freezing rather frightening experience as a result. problem, which often blocked the oxygen about 60,000 feet. “When the Arrow was cancelled and we didn’t have an aircraft that Subjects undergoing explosive decompression supply, resulted from the freezing of moisture experienced hypoxia “which we thought cleared in the pilot’s exhaled air. These masks were used would go that high, we went back to the Pate,” said Soper. “We didn’t need the other one.” up as soon as you received oxygen and returned by Royal Canadian Air Force pilots during the to a lower altitude,” Soper said. “On one war and its innovations were later used in masks Around this time, however, the issue of oxygen occasion, I found that after the initial effects, developed for British and American pilots. supply at high altitudes was beginning to extend there could be a lingering, more lasting effect While at Farnborough, Soper helped to evaluate beyond the military. “Big passenger jets were of which we were not aware.” a new, more sophisticated pressure-breathing being built and they would fly at 40,000 feet so they had to be pressurized,” said Bryan, who was The experiment was conducted in a decompression helmet being designed by a British company. chamber at a lab in Downsview and afterwards, Positive pressure breathing masks deliver oxygen assigned to investigate how long it took for passengers and the flight crew to get oxygen Soper got into his car to drive back to his office at the to the pilot’s respiratory system at higher than original IAM site on Avenue Road near downtown ambient pressure—they literally force air into the masks on. “That meant trying to figure out how long they would stay conscious.” Toronto. “I have absolutely no recollection of leaving lungs. They’re needed to maintain consciousness Downsview or of the drive itself until I found in the event of a cabin depressurization at Bryan and another officer, Wilson (Bill) Leach, myself in central Toronto near College and Bay altitudes above about 35,000 feet. devised a series of tests in a decompression Streets, having overshot my destination by Positive pressure systems are not comfortable; chamber that involved taking test subjects from several miles. When I realized where I was, they blow out the chest and lungs and make the pressure at 8,000 feet to the much lower I pulled into a parking space to try and sort breathing quite difficult because the user has pressure at 40,000 feet in a matter of seconds. things out. It was very frightening. Not only to breathe out forcefully. “Above 45,000 feet, This is known as explosive decompression—the could I not figure out why I was there but I the face is puffed up like a frog because of the kind of thing that can happen if a plane’s hatches realized that I had no memories of what had pressure of the oxygen mask,” said Charles or windows blow open or if the sealed cabin is happened. So, puzzled about the events, I drove Bryan. The pressure can also cause blood to breached in some other way. The tests were back to the Avenue Road site. It was noon when I pool in the lower body, requiring counter risky. “When decompression occurred, there was got there and my colleagues were in the bar. pressure from a pressure suit. a terrific rush of gas from the lungs,” said Bryan. I told them what had happened and there was “If you happened to have your throat closed, if

16 Flight Comment — Issue 3, 2015 a lot of laughter and teasing about my forgetfulness. closer to about 25,000 feet would be more the pursuit of his research was beyond the call of Nobody took my amnesia seriously until [Bryan] typical and “that gives you a minute or so” to get duty and has resulted in greater safety for people had a related experience a short time later. on an oxygen mask, he said. “Although there the world over who fly in high altitude aircraft.” have been rapid decompressions [in commercial “When Dr. Franks heard about these events, airliners], there have been very few of a he was horrified and said that these hypoxic catastrophic nature.” In the next issue: The article will conclude with experiences were costing us grey cells. As a the development of early ejection seat designs result, guidelines and restrictions were imposed A film of the decompression chamber tests was and combating physiological illnesses in flight. on what sort of experimental work we could distributed to the Canadian airlines and their carry out in the future. It still frightens me when pilots, providing graphic evidence of what could I think about that drive through Toronto traffic, happen in an explosive decompression. The IAM of which I have no memories at all. How lucky scientists also trained airline pilots and their not to have been involved in an accident!” research led directly to the development of the drop-down oxygen masks that are now used in The tests in the decompression chamber revealed commercial planes. Unlike the more sophisticated that passengers who experienced a sudden loss pilot’s masks, the passenger masks are round so of cabin pressure had about 15 seconds to get that people who have never seen one before and their masks in place. The situation is made more are trying to put it on under stressful conditions urgent by the fact that passenger jets, unlike “don’t have to figure out what was up and what military aircraft, can’t dive rapidly to a lower was down,” said Bryan. altitude where it would be possible to breathe without a mask. They must descend more slowly In 1960, Leach (who later became Surgeon General and at a much shallower angle or risk serious of the Canadian Forces) received the coveted structural damage. “We’ve had airliners go into McKee Trophy, which was awarded each year for a sharp descent because of malfunctions,” said “meritorious services in advancement of Canadian Bryan. “In one case, the pullout was so drastic, aviation.” The report of this award particularly the engine fell off.” emphasized Leach’s specialized work on the effects of anoxia and explosive decompression When they did tests to see if passengers could and its applicability to the new generation of survive without oxygen during a typical slow military and civilian jet aircraft. “The results of descent in a commercial airliner, “we had to this research have received national and abort every time,” Bryan said. “With the shallow international acclaim and have provided a base descent, it took a long time to get to a breathable for further research in many countries. His work atmosphere. At the rate of descent that the plane has also resulted in improved airline and military could stand, we’d get serious brain damage—even crew training techniques and the design of new young, fit people couldn’t get enough oxygen.” oxygen equipment. He noted, however, that modern airliners are “During his research work, Leach continually designed with a scoop in front that forces air into exposed himself to explosive decompression and the aircraft as it descends, providing some periods of anoxia at high atmospheric altitudes pressurization. Therefore, an explosive despite the fact that no observations had ever decompression may not drop the cabin pressure been made which recorded the effects of such as low as that at 40,000 feet. A pressure level exposure. The personal courage he displayed in

Issue 3, 2015 — Flight Comment 17 ON TRACK Alert or Bust?

This article is the next instalment FS Alert is according to Wikipedia the The Reykjavik OACC (ICAO: BIRD) deconflict of a continuous Flight Comment northernmost permanently inhabited their airspace through the call sign “Iceland contribution from the Royal Canadian C place in the world. The airport is not Radio.” This airspace is always controlled. Air Force (RCAF) Instrument Check surprisingly the most northern permanent Pilot (ICP) School. With each “On Track” runway in the world. The Russians build an So where am I going with all this? IFR 101: IFR article, an ICP School instructor will ice runway and camp very near the North flight in controlled airspace requires an reply to a question that the school Pole each year but they have yet to figure out IFR clearance! received from students or from other how to keep it from melting in the summer. RCAF flight crews are well aware of this fact. aviation professionals in the RCAF. I suspect that their communication procedures However, in busy operations and competing If you would like your question are less confusing than ours though. priority-one tasks, sometimes common featured in a future “On Track” article, Alert airport (ICAO: CYLT) is a highly controlled, practice is forgotten or missed. There have please contact the ICP School at: been several Civil Aviation Daily Occurrence +AF_Stds_APF@AFStds@Winnipeg. uncontrolled airfield. Despite the prevalence of radio communications used by the various Reporting System (CADORS) events recently ground agencies, the uncontrolled air traffic that were the impetus for this article. Just This article was written by frequency airfield is surrounded by Class G recently, a four-engine turbo-prop cargo Captain Greg Boyd, ICP Instructor. uncontrolled airspace in the Edmonton Flight aircraft that descended out of controlled It will address some recent RCAF Information Region (FIR). This uncontrolled airspace (or climbed into controlled airspace) incidents while flying in the far north. airspace (ICAO: CZEG), extends in the vertical near Alert violated the Air Traffic Control/ to the Arctic Control Area floor of Flight Level aircrew contract that guarantees IFR (FL) 270 controlled by Edmonton Area Control traffic separation. Centre (ACC). In the horizontal, this airspace There are exactly two scenarios for getting extends far to the North, West and South but to CYLT IFR, even if coming from Russia. is relatively close to the neighbouring FIR Scenario one is primarily domestic with boundary of Sondrestrom (ICAO: BGGL). significant flight time in CZEG prior to descent. Sondrestrom is uncontrolled airspace from Scenario two transits the international airspace the surface to FL195 with the exception of of BGGL (could be from southern Canada or areas surrounding the largest Greenlandic departure out of Thule AB, Greenland for airports. Above FL195, Reykjavik Oceanic Area example) and will spend minimal time in Photo: DND Photo: Control Centre (OACC) controls the airspace. CZEG. Each of these can be divided into a

18 Flight Comment — Issue 3, 2015 further two scenarios: cruise in controlled airspace with a late descent into uncontrolled airspace and cruise in uncontrolled airspace (table 1). Ok, having safely and legally arrived in CYLT, how do we get out? Specifically, how do we get a clearance to enter controlled airspace? For flight into BGGL FIR above FL195, Article 431 of the General Planning Handbook provides phone numbers to Reykjavik OACC. A valid clearance with a “void time if not airborne by” can be issued for both CZEG and BGGL with this one call. For flight solely in CZEG it is easiest to remain below FL270 and get a clearance airborne via Arctic Radio (HF 5680). The advisory traffic calls on 126.7 MHz are definitely be noticed and most likely result If fuel does not permit a restricted climb required by RCAF pilots and will definitely in a CADORS entry that affects all of us with profile, the North Bay FIC through affect grading on training trips and assessments wings on our chest. More importantly, 1-866-WXBRIEF will liaise with Edmonton on check rides. However, without a resulting it is unsafe. While the Russians continue to for the clearance. Do not simply takeoff safety incident, the Division Instrument rebuild their ice runway, let’s trap this error from CYLT and climb to FL350 because it Check Pilot is unlikely to hear about these errors. and always get clearance in controlled was on your flight plan! The omission of a required call to an ACC will airspace.

CZEG only Cruise Below FL270 FL270+ Call Edmonton centre for descent Not applicable Shall Advise “Alert traffic” on 126.7 MHz of descent and approach Shall Shall BGGL Cruise with only descent in CZEG Below FL195 FL195+ Call Iceland radio for descent (Sondrestrom below FL195) Not applicable Shall Advise “Alert traffic” on 126.7 MHz of descent and approach Shall Shall

Table 1

Issue 3, 2015 — Flight Comment 19 Risk UNDERSTANDING & in the establishment of MANAGEMENT a new capability

by Lieutenant-Colonel C.A. McKenna, Commanding Officer, 450 Tactical Helicopter Squadron

n May of 2012, 450 Tactical Helicopter inherent with developing and executing Squadron (THS) was reactivated in a new maintenance program, new aircrew I Petawawa, Ontario receiving its first procedures, the introduction of a high level state-of-the-art CH147F Chinook Helicopter of automation in a fully glass cockpit, and on 24 June 2013. The re-establishment of the the establishment of a far higher level of Chinook Medium-to-Heavy lift helicopter in the industry/ contractor dependence than tactical Royal Canadian Air Force (RCAF) represents a aviation has ever previously experienced. While transformational capability for Canada and the the challenges are many, a collective understanding RCAF. In the same manner that the introduction and constant communication of these risks and of the CC177 Globemaster represented a an open dialogue on these challenges down to significant step-change in the RCAF’s ability the lowest level remains the greatest hedge to strategically project and sustain forces, the against flight safety incidents and accidents CH147F Chinook represents a transformational within the fleet. change in the RCAF’s ability to tactically project and sustain land and special operations forces The risks associated with such a complex in the modern full spectrum battlespace. project fall into several key categories:

organizational (achieving Initial Operational Sgt Jean-FrancoisPhoto: Lauze While the aircraft is seemingly infinitely Capability/ Full Operational Capability capable, it is important to realize that the timelines and manning), technical (errors or establishment of this capability for the RCAF is inconsistencies in publications such as the waiting long periods at the unit prior to their vested solely in our people - the maintainers, Interactive Electronic Technical Publication, qualification). Alone these risks are not supporters, and aircrew that maintain, support, Standard Manoeuvre Manual, or Original insurmountable, however, when aggregated and fly this aircraft every day. In this light, the Equipment Manufacturer documentation), they present a significant leadership and flight aircraft is a tool and the people truly represent general safety (building design/ end use, fall safety challenge for squadron and wing the established capability. With this in mind, the restraint, new Aircraft Maintenance Support Command teams. stand-up of such a capability is a fundamentally Equipment [AMSE]/ tooling, etc.), procedural human activity that depends heavily on (risks associated with the development and Culture and the RCAF melting pot leadership, trusting interpersonal relationships implementation of new flying procedures and There are myriad challenges associated with within the squadron, integrity at all levels, and automation), and what could be characterized the stand-up of a new unit and a new initiative. Further, it is essential to maintain as emotional/ morale risk (complacency capability; however, the most challenging clear understanding at all levels of the risks associated with aircrew and maintainers aspect in this effort has been the

20 Flight Comment — Issue 3, 2015 establishment of a healthy safety and reporting Risk acceptance/understanding record keeping and Aircraft Maintenance Control culture within the unit. This is made more In most long-established RCAF units, change is and Repair Office errors or omissions the leading difficult with the fact while the aircrew came focused in a measured way within small pockets cause of unit flight safety incidents to date. While primarily from within the tactical aviation of the unit as we collectively deal with shifts in this is incredibly frustrating for our maintenance community, the maintainers and supporters personnel or maintenance policy, flying orders, and support teams, they continue to impress me came to 450 THS from virtually every single or mission sets. These changes are usually with their ability to pragmatically identify issues, squadron and wing in the RCAF. We have handled by unit leadership in a deliberate propose viable solutions, get buy in from the discovered that each RCAF wing has a unique manner and the risks are small, quantifiable, and Squadron Air Maintenance Engineering Officer/ maintenance culture and personality with a well understood with the majority of the unit WSM and OEM staff and get on with safely putting subtly different understanding and interpretation remaining stable. When establishing a new unit aircraft on the line. In my view, this is ‘Warrior of flight safety and maintenance policies. This and new fleet, change is constant, accelerating and Spirit’ at its best, pushing through adversity to represents a significant leadership challenge for aggregating on a daily basis. While this is achieve a collective goal, all the while balancing the senior Non-Commissioned and junior officers exciting and challenging, the aggregation or safety and ensuring that smart risk is accepted and in the maintenance and logistic support sub-units accumulation of risk associated with this pace of communicated to the appropriate level. at 450 THS who need to create understanding change is often very difficult to quantify and and communicate daily across the barriers and the management and mitigation becomes a biases that are inherent with this culture of leadership function vested in leaders at all amalgamation. levels of the unit and extending well into the ‘‘There are myriad challenges associated with the stand-up of a While this could be viewed as a significant Weapons Systems Manager (WSM), wing and challenge and a primarily negative issue, I would divisional support staff. new unit and a new capability; however, the most challenging argue the opposite. The introduction into the While there are mature and robust methods to strong and vibrant 1 Wing ‘Air Warrior’ culture deal with risk acceptance in the RCAF such as aspect in this effort has been the of fresh perspectives from elsewhere in the Record of Airworthiness Risk Management in the establishment of a healthy safety RCAF has had the effect of forcing leaders and Operational Airworthiness (OA) context and Mission and reporting culture within aviators within the unit to adapt their leadership Acceptance—Launch Authorization in the the unit.’’ styles, question why we have done things a tactical employment context, they cannot cover certain way, and in many cases adopt best every eventuality faced by a unit processing this practices from other fleets, squadrons and much change on a daily basis. My leadership wings. The key to achieving RCAF cross-cultural team spends a great deal of time and energy Industry partnership and culture integration at 450 THS has been an open mind discussing and managing the aggregated risk 450 THS is unique in 1 Wing in that we have in place and a willingness to listen and adapt to new at 450 THS. A key example of this is that our a 20 year in-service support contract with Boeing to ideas. In doing so, I believe we have built a maintenance procedures are often found to be support the Chinook both at the main operating strong and flexible maintenance and support incomplete, needing clarification and immediate base and while deployed domestically or organization. The 1 Wing leadership mantra re-drafting by the OEM with Director Technical internationally. While all maintenance activity is of making sure our aviators are “well-trained, Airworthiness and OA approval. This is compounded conducted by RCAF technicians supported by Boeing well-led, and well-equipped” is complemented with the Chinook being one of the first Field Service Representatives, the entire supply by ensuring a flexibility of mind and a operational Defence Resource Management chain for the aircraft in addition to tool control and willingness to listen when approaching all of Information System fleets making maintenance these emerging issues and challenges. Continued on next page

Issue 3, 2015 — Flight Comment 21 22 considered and integrated from a flight flight a from considered and integrated to be and need RCAF ofthe those with companies are now intertwined of these fully to note that cultures corporate the important is it partnerships, industry enduring these to While are there great benefits instructors. by ofcivilian amix and military instructed aircrew being that sees civilian partnership (CAE)Aviation in aunique military/ Electronics unit by the within Canadiansupported is delivery aircrew training and courseware Similarly, by and Boeing their sub-contractors. AMSE is supplied, calibrated, and maintained

Flight Commen t —Issue 3,2015 professionalism, and risk awareness ofour due to forces determination,operations the land our for and special aviation effects succeed and tactical deliver transformational new helicopter. in this incredible nested It will succeedor due to advanced the technology Ultimately, up will not stand this capability and integrated. is espoused unit ofthe culture Flight Safety that extant the organizations that have allowed usto ensure ofthese dialogue and both open constant with safety perspective. Thankfully, we have we Thankfully, perspective. safety

By Air toBy Battle! ‘‘Air at Warriors’’ 450 single THS day. every resilience and professionalism 1Wing ofthe byamazed proud and the made incredibly mitigating such asthis. Iam risk in programs organization, ofmanaging capable and core ofwhat makes alearningvery RCAF the encouragement oftheir leadership is at the and judgement to support challenges the with and to applytheir experience and freedom trust, at centre the ofthis capability. Their abilities and aviators thattechnicians, are supporters,

Photo: Corporal Nicolas Tremblay Photo: MCpl Roy MacLellan USE IT or LOSE IT Without practice, pilots find that some flying skills — especially cognitive skills — grow weak.

by Linda Werfelman Reproduced with permission from and manual control skills remained strong, automation systems were designed to give AeroSafety World Magazine. even among pilots who said they practiced pilots more time to think about and plan for them infrequently. upcoming portions of the flight, instead, during xtensive use of automated cockpit systems uneventful periods, their minds sometimes Casner and his research team based their causes pilots to lose proficiency in some wandered.1 E cognitive skills required for manually conclusions on results obtained when 16 airline flying an airplane—such as keeping track of pilots flew routine and non-routine flight The report on the new study, published in the aircraft position without using a map display— scenarios in a Boeing 747-400 simulator. December 2014 issue of Human Factors, noted although other skills remain relatively intact The researchers varied the level of automation that a research report published in 1971 said over a long period of time, a new study says. in use, graded the pilots’ performance and that pilots had varying degrees of success in asked questions about their thoughts during remembering different types of skills.2 The study, led by Stephen M. Casner of the simulator sessions. the U.S. National Aeronautics and Space Continued on next page Administration (NASA) Ames Research Center, A companion study, conducted during the found that pilots’ instrument scanning skills same simulator sessions (AeroSafety World 7-8/14, p. 26), found that, although cockpit

Issue 3, 2015 — Flight Comment 23 “The researchers found that when [hand-eye performed by automated systems and “We asked each pilot to fly during three phases skills such as those used to scan instruments occasionally shutting off those systems to of flight (i.e., arrival, approach and missed and manipulate flight controls] were initially practice manual flying skills. approach) in the three automation conditions,” well learned, they were surprisingly resistant the report said. “To save time, we did not ask to forgetting, even after four months of To determine how effectively these methods pilots to fly all three flight phases using the inactivity,” the 2014 report said. “Another type help pilots retain their manual skills, the autopilot, as we did not expect to see much of skill considered in the study is the set of researchers asked seven captains and nine variation in pilots’ performance across the three cognitive skills needed to recall procedural first officers, all of whom worked for U.S. air flight phases when the autopilot was used.” steps, keep track of which steps have been carriers, to participate in the 747-400 simulator completed and which steps remain, visualize study. The pilots had an average of 17,844 flight Researchers scored the pilots on their ability the position of the aircraft, perform mental hours, including an average of 623 hours in the to comply with course, altitude and speed calculations and recognize abnormal situations. 12 months before the simulator evaluation and assignments on the route. Like researchers before them, [this team] found 13 hours during the previous week. Participating pilots said that they had accumulated 73 percent In their responses to a research survey, the that after four months of inactivity, pilots’ participating pilots said that they had “strong cognitive skills had significantly deteriorated. of their total flight hours in airplanes equipped with a flight management computer (FMC) background in basic instrument flying, The 1971 research was used at the time as and 89 percent of their time in airplanes moderate recent experience in flying without guidance for regulators responsible for setting with flight directors. an autopilot and very little recent experience minimum recent experience requirements for flying with both the autopilot and flight pilots, the new report said. Hand-Eye Skills director turned off,” the report said. To enable the researchers to evaluate the “The wisdom provided by this early research Table 1 shows how pilots performed—and pilots’ hand-eye skills—their instrument 3 is evident in the regulations we have today,” how many times they committed significant scanning abilities and their manual control of the report said. “Pilots can wait almost two deviations from speed, altitude or course—in the airplane—the pilots flew routes that had years without flying and still operate under the three different automation conditions and been programmed into the simulator’s FMC visual flight rules (with no passengers aboard). three phases of flight. with three different combinations of automation. If they want to exercise the privileges of operating The researchers’ analysis of the results showed under the more cognitively demanding The autoflight phase involved use of the that during the arrival and approach phases, instrument flight rules, six months of autopilot, flight director and autothrottle to there was “no significant association between inactivity is the limit.” follow the route programmed into the FMC. automation condition or recent practice on pilot The manual control phase involved use of the Today, the report added, concern about performance,” the report said. In the missed flight director and autothrottle system along deteriorating pilot skills centers on inactivity approach phase, researchers found “a significantly with manual manipulation of the control yoke associated with the increasing use of cockpit higher likelihood of a speed deviation in the “in response to flight director commands that automation to do everything from performing manual control condition when compared to directed them along the FMC-programmed fuel calculations and tracking the aircraft’s the raw data and manual control condition... route,” the report said. In the raw data and position to reconfiguring navigation equipment Pilots’ scanning and manual control skills manual control phase, pilots followed the same and monitoring and identifying instrument seemed to be more likely overwhelmed in the route while manipulating the control yoke, system failures. midst of this high- tempo phase of flight.” controlling thrust levels and relying on primary Nevertheless, cockpit procedures have retained flight instruments for information. methods intended to prevent a lack of use from leading to a deterioration of pilots’ manual flying skills, by closely monitoring the work

24 Flight Comment — Issue 3, 2015 Table 1 : Pilots’ Flying Performance (Instrument Scanning and Manual Control Skills) in Three Automation Conditions

Automation Condition Raw Data and Flight Phase Autoflight Manual Control Manual Control Arrival Off course (3 course assignments per pilot) 0% (0 of 48) 0% (0 of 48) 2% (1 of 48) Speed deviation > 10 kt 8% (4 of 48) (M = 17 kt) 23% (11 of 48) (M = 15 kt) (7 of 48) (M = 42 kt) (3 speed assignments per pilot) Altitude deviation > 300 ft 2% (1 of 48) (M = 740 ft) 10% (5 of 48)(M = 968 ft) 10% (5 of 48) (M = 732 ft) (3 altitude assignments per pilot) Approach Off localizer 0% (0 of 16) 6% (1 of 16) (1 localizer assignment per pilot) Off glide slope (1 glide slope 0% (0 of 16) 13% (2 of 16) assignment per pilot) Speed deviation > 10 kt 0% (0 of 48) 6% (3 of 48)(M = 21 kt) (3 speed assignments per pilot) Altitude deviation > 300 ft 0% (0 of 48) 0% (0 of 48) (3 altitude assignments per pilot) Missed Approach Off course (1 course assignment per pilot) 6% (1 of 16) 13% (2 of 16) Speed deviation > 10 kt 6% (2 of 32) 38% (12 of 32) (2 speed assignments per pilot) Altitude deviation > 300 ft 0% (0 of 16) 6% (1 of 16) (M = 310 ft) (1 altitude assignment per pilot) M = mean Note: Based on actions of 16 pilots in a Boeing 747-400 simulator. Data in cells refer to percentage of tasks during which pilots committed at least one operationally significant error Source: Casner, Stephen M.; Geven, Richard W.; Recker, Matthias P.; Schooler, Jonathan W. “The Retention of Manual Flying Skills in the Automated Cockpit.” Human Factors Volume 56 (December 2014): 1506–1516

Continued on next page

Issue 3, 2015 — Flight Comment 25 The results supported the findings of earlier Cognitive Skills Table 2 shows how pilots performed on eight research that, as long as pilots had been The participating pilots were unanimous in navigation tasks—and how many times they formally trained in instrument scanning and telling researchers that, although they had committed at least one operationally 4 manual control, those skills were “reasonably strong backgrounds in conventional navigation significant error —while flying an arrival, well-retained, even in the absence of regular methods, they had no recent experience in approach and missed approach without using practice.” Nevertheless, the study said, the that area. an FMC. For this portion of the study, researchers results also showed “some atrophy [in those compared each pilot’s performance while using skills] that perhaps merits additional practice.” the simulator’s FMC against his or her performance using a conventional VHF omnidirectional radio (VOR) receiver. Table 2: Pilots’ Performance When Navigating Without the Use of the “Aside from requiring different procedures to Flight Management Computer operate them, the two types of navigation equipment differ more strikingly in how much Navigational Task Deviations pilot involvement they require,” the report Tune VOR station 6% (1 of 16) said. “Whereas VORs require the pilot to closely (1 opportunity per pilot) follow the progress of the flight and reconfigure Navigate to VOR station the equipment as [the airplane] arrives at each 6% (1 of 16) (1 opportunity per pilot) waypoint, the FMC permits the pilot to Altitude deviation > 300 ft 16% (5 of 32) program the entire route prior to departure (2 opportunities per pilot) (M = 4,686 ft) and to think of the navigation process as a ‘once-and-done’ programming exercise.” Speed deviation > 10 kt 0% (0 of 32) The process included three specific (2 opportunities per pilot) unannounced instrument system failures as Final approach course 25% (4 of 16) part of the test of pilots’ abilities to recognize (1 opportunity per pilot) and confirm an abnormal instrument indication Missed approach point by cross-checking their instruments. The failures 44% (7 of 16) (1 opportunity per pilot) involved the participating pilot’s heading Approach minimums indicator and altimeter—although heading 19% (3 of 16) (1 opportunity per pilot) indicators and altimeters elsewhere in the cockpit continued operating; and blocking Missed approach heading 38% (6 of 16) the pitot-static system, which caused (1 opportunity per pilot) malfunctions in all airspeed indicators in the M = mean; VOR = VHF omnidirectional radio cockpit. The engine indicating and crew Note: Based on actions of 16 pilots in a Boeing 747-400 simulator alerting system also was disabled. Source: Casner, Stephen M.; Geven, Richard W.; Recker, Matthias P.; Schooler, Jonathan W. “The Retention of Manual Flying Skills in the Automated Cockpit”, Human Factors Volume 56 (December 2014); 1506–1516

26 Flight Comment — Issue 3, 2015 Table 2 shows that all pilots were able to hold their airspeed within allowable limits and all Table 3: During Three Instrument System Failure Events but one were able to tune a VOR station and select an inbound course; in addition, only one System Failure Event and Pilot Action Proportion of Pilots pilot had difficulty navigating to the VOR Altimeter lag station. But six pilots failed to fly the published heading on the missed approach, and seven Verbalized problem 100% incorrectly announced their arrival at the missed approach point. Only one pilot Cross-checked instruments 69% completed the entire process without errors. Deviated from altitude 75% “Overall, like instrument scanning skills, pilots Diagnosed problem 81% reported that navigation skills, once initially mastered, are seldom, if ever, practiced,” the Heading indicator skew report said. “But rather unlike instrument Verbalized problem 94% scanning skills, which are resistant to forgetting, navigation skills that have been Cross-checked instruments 63% supplanted by the use of cockpit automation are highly susceptible to forgetting and likely Deviated from heading 38% require frequent practice to keep them sharp.” Diagnosed problem 56% In its analysis of the pilots’ responses to the Unreliable airspeed three events involving instrument system failure, the study noted that 81 percent of Verbalized problem 100% participants told researchers that they had received “considerable training and practice Cross-checked instruments 94% with recognizing and dealing with puzzling Approached stall (number of stick 94% instrument indications.” However, fewer than shaker activations) (M = 4.6, SD = 4.0) half said their airline recurrent training had included similar practice. Diagnosed problem 94% Table 3 shows that in each of the instrument M = mean; SD = standard deviation system failures—altimeter lag, heading Note: Based on actions of 16 pilots in a Boeing 747-400 simulator. indicator skew and unreliable airspeed—all Percentages indicate number of pilots who took the indicated action but one of the pilots verbalized the problem. Source: Casner, Stephen M.; Geven, Richard W.; Recker, Matthias P.; Schooler, Jonathan W. Continued on next page “The Retention of Manual Flying Skills in the Automated Cockpit.” Human Factors Volume 56 (December 2014): 1506–1516

Issue 3, 2015 — Flight Comment 27 In dealing with altimeter lag and heading dealing with puzzling instrument indications, indicator skew, fewer pilots correctly took the our findings suggest that this sort of skill is next step—cross-checking instruments. vulnerable to forgetting and could also benefit In the case involving unreliable airspeed, only from more emphasis during initial and one pilot failed to make “an obvious attempt” recurrent training. to check the other instruments. This article is based on “The Retention of In two of the three scenarios—altimeter lag Manual Flying Skills in the Automated Cockpit,” and unreliable airspeed—most of the pilots by Stephen M. Casner, Richard W. Geven, deviated from the assigned altitude and failed Matthias P. Recker and Jonathan W. Schooler, to prevent the approach of a stall, respectively. published in Human Factors, Volume 56 They were better at coping with heading (December 2014):1506–1516. indicator skew, with 38 percent deviating from the assigned heading. References 1. Casner, Stephen M. and Schooler, Jonathan W. Heading indicator skew was the easiest of the “Thoughts in Flight: Automation Use and three problems to diagnose, the report said, Pilots’ Task-Related and Task-Unrelated noting that only one pilot failed in his Thought.” Human Factors Volume 56 diagnosis. Eighty-one percent successfully (May 2014): 433–442. diagnosed the case of altimeter lag, and 56 percent correctly identified the heading 2. The current study cited Mengelkoch, indicator skew, the report said. R.F., Adams, J.A. and Gainer, C.A. “The Forgetting of Instrument Flying Skills.” Data showed that pilots who reported that Human Factors Volume 13 (1971): 397–405. they had at least occasionally had practice during recurrent training in dealing with 3. Deviations were classified as “significant” puzzling instrument indications performed if airspeed was more than 10 kt from the no better than the others in the three assigned speed, if altitude was more than instrument failure scenarios. The report said 300 ft above or below the assigned altitude that one explanation might be that the and if a full-scale deflection was recorded recurrent training focused on “a few familiar on a course deviation indicator. failures” and did not include general methods 4. Airspeed and altitude deviations were of handling other types of abnormal events. scored as outlined in Note 3. While navigating to a VOR or a missed approach “Overall,” the report said, “the data suggest point, deviations were recorded “when that pilots performed well at detecting failures pilots missed the assigned point by more but often neglected to cross-check other than 3 nm [6 km]” or flew more than instruments, diagnose the problem and avoid 10 degrees off an assigned heading. the consequences of an unresolved failure. In regard to the reported frequency at which pilots receive initial and recent practice in

28 Flight Comment — Issue 3, 2015 Photo: DND Photo:

Expanding Flight Safety South of the Equator

by Captain Dave Henriquez, Liaison Officer, Canadian System of Cooperation Among the American Air Forces

e often take Flight Safety (FS) for exercise, one thing that was neglected was objectives were completely ignored. During the granted until an accident or incident the topic of FS. With multiple aircrafts ranging 2014-2015 SCAAAF cycle, the main objectives W occurs. The heightened awareness from Beechcraft King Airs to CC177 Globemaster IIIs were to update the various manuals including becomes more prevalent when conducting conducting strategic airlifts to search and the FS manual. combined air operations with foreign nations. rescue missions conducted by light to With the built up excitement of conducting medium-lift helicopters, it became evident This particular task was assigned to the operations with other air forces, one tends to that steps were needed to implement a FS Royal Canadian Air Force, because of their put aside the importance of FS and the impact culture to address the various reports that commitment and profound leadership in this it could have if not taken seriously. This was the the aircrews were submitting. particular topic. The Canadian SCAAAF LO in case during a recent System of Cooperation concert with the Directorate of Flight Safety Among the American Air Forces (SCAAAF) air The evaluation cell assigned to the exercise has made significant improvements to the operation exercise COOPERACION III conducted took these considerations into account and SCAAAF FS manual and will present it at the in Lima and Pisco, Peru back in April 2014. included the FS concerns into the after action next SCAAAF conference. The new and report. As part of the SCAAAF Campaign Plan, improved FS manual will serve as a guiding The main purpose of the exercise was to the promotion of a FS culture was one of the document for future SCAAAF exercises to support the Peruvian government in the event main institutionalize objectives that needed address FS concerns both in air and ground of an earthquake and tsunami. Secondly, it was attention. For the last couple of years, the operations. Because SCAAAF is conducted in to validate the SCAAAF combined air operations SCAAAF organization was mainly focused on the Spanish language, the Canadian SCAAAF manual and put to practice the lessons learned applying the procedures for the conduct of air LO will have the responsibility to act as the from the virtual exercise, which was conducted combined operations in support of Humanitarian Canadian ambassador to all FS matters in April 2013 in Mendoza Argentina. During the Aid and Disaster Relief HADR. These institutionalized within the organization.

Issue 3, 2015 — Flight Comment 29 LESSONS LEARNED

Sleeping DND Photo: AT THE WHEEL by Captain Dan Gillis, Pilot, 413 Search and Rescue Squadron, Greenwood

t was a cold Sunday evening in January of With HF communications working just enough to back to Goose Bay and landing just before 2012 when our CH146 Griffon lifted off not give up on them and not well enough to pass 3 a.m. The patient was transferred to the I heading 60 nautical miles north east traffic we continued the search. With no luck on awaiting ambulance and we finished up what of Goose Bay. Earlier that evening, a little after HF and fuel remaining for on scene quickly we had to before heading out the door. nine, I received a call from Rescue Coordination disappearing, we landed nearby in order to try Centre (RCC) to pick up a sick hunter suffering our satellite phone. We didn’t have the best track I have always found that after a few hours of from abdominal pains. He was in a hunting party record with it, so it was not our go-to option for wearing NVGs I can’t go straight to bed. I find I of 8-10 people that set up camp beside a lake a communications. The landing was made difficult need to stay up for about an hour to let my eyes few days before. The patient was unable to travel by the recent snow fall and the lack of proficiency relax. So I headed down to the local coffee shop on a snowmobile due to his pain. in landing under snowball effect conditions. for a late night snack. On my way back I thought It took a few minutes to find a place that was I missed my turn not once, but twice! Here I was 444 Squadron is a secondary Search and Rescue large enough to land safely yet provide adequate barely able to drive back to my house, and yet (SAR) asset and at the time, no crews were references. The SAR Technician slugged through I was flying less than 45 minutes earlier. dedicated to be on standby. I called around and the snow with snowshoes and called the hunting I learned a lot of things that night, but the mustered up a crew and checked the weather: party on the satellite phone to get the correct cold, mostly clear, great visibility with westerly biggest thing is that we are very poor at coordinates. We found out later that the hunting recognizing how fatigued we are. Even though winds around 20 knots. I was thinking what a party gave RCC the wrong ones! By this time, we great night to have my first mission as a SAR our crew day was less than 6 hours, most of us did not have enough fuel to pick up the patient were up for 20 hours. Even more, none of us Aircraft Captain: a quick flight out to pick the and make it home, so we headed back to base guy up, back in bed before midnight. expected to work that day, so we never put any to refuel. of the safe guards like an afternoon nap into When we got on scene we could not see any sign Shortly before 1 a.m. we launched on our second place. It’s important to note that when thinking of the camp. We started a high expanding square attempt. This time everything worked out. about crew day, one needs factor in time awake and I started to work the high frequency (HF) We found the hunting party and after a quick and take the whole day into account, not just radio trying to confirm the coordinates with RCC. assessment we had our patient onboard heading time at work.

30 Flight Comment — Issue 3, 2015 LESSONS LEARNED

Crossing Over by Captain Dean Vey, 413 Transport and Rescue Squadron, Greenwood

‘ e-treading’ to a new aircraft is something Griffon-Cormorant converts, there is almost We departed St. John’s and set out to cross all Royal Canadian Air Force pilots always a desire to take manual control and do Conception Bay, over 14 NM of water. Weather R experience. During initial training in something more quickly than to fly through was as expected, visibility was about six miles Portage La Prairie and Moose Jaw, the transition (and sometimes against) the automation. and we were transiting 600-800 feet with is always challenging and students must keep Rarely is this actually required. the aircraft trimmed but no autopilot systems adapting after relatively short periods on various engaged. During the eight minute or so aircraft. After training, students are selected for A few months after being at 103 SAR Squadron, crossing, the rain and mist started to intensify their first tour aircraft type, and begin to develop we were on a training flight one afternoon, and I slowed and descended the aircraft from years of ‘muscle memory’ and flying techniques flying home from St. John’s to Gander, which is 130 knots down to around 100 knots and that eventually become a part of their instinctive about a 45 minute flight direct. We wanted to brought the altitude down to about 500 feet. flying behaviour. These instincts can be difficult do some overland training along the way but The approaching shoreline was about three to change for many pilots and it takes a varied knew that we may have to work around some miles away and immediately rose 100-200 feet period of time for them to erode after transition, onshore fog, drizzle and low cloud along the on land with a peak of about 900 feet just three especially during hi stress or unexpected way. Having the entire afternoon at our disposal, miles inland. In what seemed like a matter of situations, where things can revert in a heartbeat. we were in no rush with lots of options. If the seconds, there was a drop in visibility down to weather was unworkable enroute for visual about 1/8th of a mile due to a rapid onset of I had completed close to 1,200 hours on the flight rules (VFR) training, we would contact precipitation and/or encountering low level CH146 Griffon in a Search and Rescue (SAR)/ air traffic control (ATC) for an instrument flight mist behind it. Instincts kicked in to not lose Combat Support Squadron role in Goose Bay rules (IFR) clearance to get through it, a procedure visual meteorological conditions (VMC), so with when I transitioned to the CH149 Cormorant in used very often for SAR missions and frequently my eyes on the ocean below us, I immediately Gander. This was a significant aircraft upgrade for training given the unpredictability of this depressed the trim release button and eased in capability and complexity, requiring more type of weather. In fact, we trained regularly the altitude down to roughly 400 feet, all the than a few modifications to my flying technique. for unplanned IFR scenarios with new First while aggressively bringing the speed back as Most of these involved managing autopilot Officers (FOs) so they were familiar with the slow as 40 knots, while simultaneously cross systems that were designed to relieve workload, procedure of acquiring an IFR clearance over checking our altitude on instruments. Success! and certainly do so when used effectively. satellite communications direct with ATC in Unfortunately, initially for many of us Gander. The forecast for the Gander area was Continued on next page going to be VFR all afternoon. Photo: DND Photo:

Issue 3, 2015 — Flight Comment 31 LESSONS LEARNED

I had prevented us from going further into bad weather. Each one of those aircraft Encountering bad weather on SAR missions is instrument meteorological conditions (IMC). deficiencies no longer existed for me on this unavoidable when you are at the pointy end Let’s press! This was much to the surprise, aircraft and, while going IIMC was to be of things and trying to save a life. Pilots are however, of the aircraft captain (AC), who had avoided, it was no longer something that forced to fly in unfavorable conditions below only flown in Cormorant aircraft. The same required the fastest hands and feet in the West. normal minima and have a mandated could be said for the rest of the crew who responsibility to do it so that ‘‘Others May were also puzzled as to what was going on In my scenario, a simple 180 degree level Live’’. That said, risk can always be managed that required such a rapid maneuver. As we turn back to better VMC would have sufficed. and the proof is in the planning. Having a leveled at better visual conditions, I felt his Engaging an autopilot in radar (RAD ALT) or fluid and adaptive plan as weather conditions hand pressure on the cyclic pushing forward barometric altimeter (BAR ALT) hold to the change is vital, as is having the various aircraft encouraging me to increase airspeed to a already perfectly-trimmed aircraft would autopilot holds prepped, strong Cockpit more comfortable 60 knots, and we both have been even better, allowing us to raise Resource Management and a fully briefed crew. looked at each other for a moment wondering the nose using the trim switch and slow the Had I had used the radar to paint the shoreline what the other was thinking. To me this was a airspeed (without climbing) and prevent with the low height warnings set for a specific perfectly executed rapid deceleration that further entry into the IMC throughout the altitude as required, I could have briefed the kept us out of IMC which I had witnessed and turn. Alternatively, having the radar up and crew on the actions I would take if we were to conducted myself on a Griffon in the past. displaying the upcoming coast would have lose visibility and successfully followed my IIMC To this Cormorant-only AC however, it was a plan. As it turned out, I didn’t voice one, and completely unnecessary and dangerous tactic reacted more than anything. A lesson that I try that he had most likely never seen anyone to pass on to every one of my FOs to this day. perform in these benign conditions! It took ‘‘We are all the product some reflection in the hours following but of our experiences and while In summary, we are all the product of our I came around to completely agreeing our instincts may be necessary experiences and while our instincts may be with him. necessary and appropriate on one aircraft, they and appropriate on one aircraft, may not be on others. Our training institutions We turned the aircraft around 180 degrees they may not be on others.’’ do a great job teaching to a standard that is the back toward the better VMC, proceeded to same for all pilots on that applicable course. get our IFR clearance and continued IFR. It is our responsibility, coming from different Once enroute, we discussed the reasoning aircraft and backgrounds, to fill in the gaps in and the options for what had just happened. allowed a controlled reduction of speed and the new procedures with “what don’t I have Inadvertent IMC (IIMC) in a Griffon was trimmed decent on RAD ALT mode with an to do now, what instincts may no longer be basically avoided at all reasonable costs for accurate depiction of land in front of us that applicable?” The key to avoiding a muscle a number of reasons, including no anti-icing would be easily monitored and avoided. As a memory reaction is planning to avoid it before capability, no approved GPS direct capability, less desirable option, we could have initiated it happens. no weather radar, with autopilots that an immediate climb with the knowledge of sometimes had to be disengaged and the aircraft the highest elevation of the terrain in front or manually flown if they proved insufficient to around us would have given us a minimal handle the conditions (turbulence, etc). Most safe altitude. All these very calm, controlled Griffon pilots were often very low on IFR options were available at any time, well actual flight time and generally avoided it for within the margin of safety; they only the simplicity and ‘comfort’ of VFR, even in needed one thing: a solid IMC plan.

32 Flight Comment — Issue 3, 2015 LECONSLESSONS APPRISES LEARNED Photo: Sdt Lindsay Grimster Lindsay Sdt Photo:

The Holes Align by Captain Andrew Rees, Air Traffic Controller, 19 Wing Comox

f you have spent any time in an operational The aircraft requested airways with a runway require the aircraft to conduct a 330 degree position, you have undoubtedly suffered 36 departure and a flow time of 6:45 a.m. turn on course. As the ground controller had I through your fair share of Flight Safety Runway 36 is Comox’s secondary runway, and not yet arrived and signed on duty, the taxi briefings that try to explain to you the Swiss is frequently used by civilian itinerant traffic clearance for runway 12 was issued by the Cheese Model. Then, one day, a situation arises due to its proximity to the civilian ramp. tower controller, who subsequently missed the that so perfectly fits this paradigm that the Following coordination with the overnight crucial taxi notification call to the terminal that importance of Flight Safety really hits home. tower controller, I issued the following includes the runway the aircraft is taxiing for. In aviation, we all know proper phraseology clearance: “Cleared to Vancouver via Comox To make matters worse, the aircraft failed to and clarity is paramount—there simply isn’t LIBOG SOUND3 arrival... depart 36 turn right query the tower controller about the runway room for ambiguity or misinformation. So, when climb on course” and it was read back correctly. change or request the required amendment to an IFR aircraft departs the wrong runway and the departure clearance. Instead, the aircraft no one, not even the pilots, realizes the error, Ten minutes later the aircraft began its taxi for requested to taxi for a full length departure vice it shows you just how important standard departure, just as the morning controller took the intersection departure issued by the tower. procedures really can be. over in the tower. It was here the system began to break down. The night tower controller had I had just finished briefing my trainee into It was a typical weekday morning in the Comox incorrectly briefed the oncoming controller the position as the tower called and requested Military Terminal Control Area with the usual that the aircraft had airways for a runway release of the aircraft off 12 with a flow of 45. rush of civilian departures to Vancouver from 12 departure. Now, to provide a bit of context— Instead of responding with the proper several different airports. Flow control was in if the same aircraft were to depart 12, Comox’s phraseology, which would be “(callsign) clearance effect, which is how larger airports such as primary IFR runway, the clearance would read: valid runway 36 with a flow of 45” the trainee Vancouver manage the acceptance rate of “...depart 12, turn left climb on course” barring responded with “(callsign) clearance valid with aircraft from a particular airspace, by issuing any other restrictions due to traffic. A right a flow of 45”. At this point, having myself departure times which must be met +/- 2 minutes. turn, which was the clearance issued with the Continued on next page Among those departures was a Beech 1900 36 departure, would turn an aircraft departing flight-planned from Comox at 6:30 a.m. 12 south toward mountainous terrain, and

Issue 3, 2015 — Flight Comment 33 34 departure clearance; tower the departure controller failed an runway amendment to change its request or tower the onthe to query failed aircraft the clearance runway; being to issued wrong the taxi towerin that resulted controllers between onhandover passed wasincorrectly Information isHere sequence ofwhat the wasmissed: to line an event upfor such asthis to occur? whatSo went wrong? How many had holes incident. was able to further continue without that Fortunately, haderror unfolded. flight the “airborne 12” aircraft the clear the and became it tower. later moments Afew tower the called and validation theco-ordination calls with inof always phraseology using proper to toI began explain importance my the trainee that tower the missed 12 stated and not 36,

Flight Commen LESSONS LEARNED t —Issue 3,2015 operating the flight. While it is fortunate that flight. the operating Whilefortunate it is terminalas the controller, to pilots the tower the morning, from controllers, to myself that working person breakdown every from Many this were that steps caused missed runway. wrong the off rotated aircraft the before would have corrected been is than more it likely missed been that issue the had asinglecertain, above oneofthe not steps validation.during While we will ever know for my trainee’s omission runway ofthe number validation to and immediately Ifailed correct runway 36 clearance in the to specify failed validation; for request terminal the trainee runway 12 towerthe controller specify in their to hear terminal andthe failed Iboth trainee call the toto terminal; notification make taxi the play in role maintaining acrucial Flight Safety. phraseology, clarity, to all detail and attention repercussion. potential Proper the serious for how evenunderscores asmall deviation has norm,to this the scenario deviate from tempting be and areason while can it for exists easily have worse. much Standard been phraseology result,outcome the asa otheror traffic could to aircraft the wasno negativethere impact

Photo: Sgt Norm McLean, Canadian Forces Combat Camera LECONSLESSONS APPRISES LEARNED

DUDE Where’s MY JET? by Sergeant T.W. Blackwell, 410 Tactical Fighter (Operational Training) Squadron, Cold Lake

t was a busy deployment with a typical day the line up as he could not find his jet, to which A seemingly small error could have had much consisting of 30-plus launches a day. We we guaranteed it was out there. Shortly he came greater issues and consequences. What if the I had just completed our handover and were back in and stated that it wasn’t. It dawned on aircraft had the wrong configuration for an in the process of launching the last wave of the us that a pilot had inadvertently taken the actual mission? What if the jet was actually day. The jets were to leave at the same time wrong jet, an easy mistake to do with the tail unserviceable and went airborne, even with but were being slightly staggered as armament numbers being 776 and 778. A quick review of the many back-up systems built in to the reconfigurations needed to be completed and the servicing set showed the pilot had indeed Hornet nothings stops a fuel leak fire. signed for before the jet could be weapon- signed for 776 and taken 778. systems released. Better situational awareness, and an extra In this case with both jets scheduled for the second of time could have prevented this Two sets of pilots had already taken off and the launch and with the same configuration, both occurrence. In this case it was lucky that the very last two were on the way out the door. before-checked and weapon system released, jet was exactly the same configuration as After stepping a pilot came back in to recheck it was not a huge issue but nonetheless a Flight required and serviceable. Safety incident. Photo: DND Photo:

Issue 3, 2015 — FlightFlight CommentComment 35 LESSONS LEARNED

Short on Time by Master Corporal Tim Brown, Canadian Forces Environmental Medicine Establishment, Toronto

orking in an Aircraft Life Support Later that week when reviewing the flying Regardless of the reason it was a risky move as Equipment (ALSE) shop can be a very schedule, we noticed that Pilot A was flying these harnesses are fitted and sewn to each W rewarding position. It can also be that day. We assumed that he would be in the individual user. Ejection while wearing an very busy when it is part of one of the Royal shop to see us before the flight to try on his improperly sized harness not only could injure, Canadian Air Force’s tactical fighter squadrons. harness. We got to work on other things in but kill. Use of ALSE is for the users’ exclusive the shop and didn’t realize that the time when use and shall not be used by other personnel. Pilots that fly the CF188 Hornet wear a large Pilot A was to have launched had come and amount of equipment which is maintained by gone. Initially we thought that the flight may There may have been other steps that we in the the first line ALSE shop. Helmets, masks, have been cancelled until we saw that all the ALSE shop could have done to remind the pilot g-pants, survival vests, and many more require remaining pieces of Pilot A`s gear was missing that this inspection was due and that his maintenance and inspections at regular from his locker. How could he be flying we harness was in our shop. This may have averted intervals. One of the pieces of gear that is worn thought, without his harness. A quick glance to the condition in which Pilot A chose to use Pilot is the PCU-56P torso harness. This harness is the right in the next locker revealed that Pilot B`s harness. This doesn’t absolve the ALSE shop wearable and provides restraint in the seat of B’s gear was complete with the exception of a of all responsibility however; in the end it`s the the aircraft and serves as a parachute harness torso harness. users responsibility that his or her gear is used in case of ejection. This harness gets inspected and cared for properly and that it’s inspected more than once during a year and one of these It was revealed after the flight that Pilot A by trained and qualified Aircraft Structures inspections includes a suspension check with did use the torso harness belonging to Pilot B Technician. It is worth a little extra time to ensure the pilot. instead of his own. Pilot A may have forgotten that your ALSE is ready to go before you need it about the harness until too soon before his so it can be depended upon to save your life. We in the 409 Squadron ALSE shop had flight to have the suspension carried out. determined that one of those harnesses was due for an inspection. We notified Pilot A via email (which was the norm) that this suspension check was required in about a weeks’ time. Within a day or so a response from Pilot A was received acknowledging the requirement for the suspension check and that he wouldn’t be in for at least a couple days. Along with the suspension check there is also an inspection of the harness that needs to be done so we brought the harness into the shop to carry out this inspection. We decided to keep it in our shop to facilitate the suspension check when Pilot A came in to see us later in the week. Photo: DND Photo: Photo: DND Photo:

36 Flight Comment — Issue 3, 2015 TYPE: CC15004 Polaris LOCATION: Op IMPACT DATE: 8 May 2015

n 8 May 2015 at 15:10 local, the CC150 aircraft system pages on the Electronic Centralized The investigation is working with the aircraft departed its base of operation for an air Aircraft Monitoring system, and nothing unusual original equipment manufacturer to inspect O to air refueling mission in support of was found. The flight continued without further the damaged elevator and gather data in an Op IMPACT. Upon successful completion of the incident and landed safely at 20:24 local. attempt to explain the failure mode. mission the crew commenced their return home. Approximately 4h into the flight and 1 h 15 min Upon landing, an exterior inspection revealed from landing, the crew felt a significant, sudden delamination of the right hand Elevator trailing vibration which lasted approximately 3-4 seconds, edge. Damage was assessed as minor. and was felt in the control column and rudder pedals on the flight deck, as well as generally throughout the aircraft. The crew checked all Photo: DND Photo: Photo: DND Photo:

Issue 3, 2015 — Flight Comment 37 TYPE: Schweizer 2-33 C-GCSK LOCATION: Lachute, QC DATE: 16 May 2015

his was a training flight in support of Shortly thereafter, at about 200 feet above The investigation is focusing on the cause of the Air Cadet Gliding Program. The flight ground level, the glider released, turned to the the tow plane loss of power; specifically, the T was part of the Annual Proficiency Check right and was last seen dropping into a wooded carburetor heat box rigging. The circumstances, for a passenger carrying qualified cadet. The area. The tow plane regained power, and was decisions and actions related to the release of the accident occurred during the initial climb out able to return to the airfield without further glider are also being examined. on aero-tow using the L19 Superdog. incident. The glider was not able to reach a field nearby, and landed in some trees. It fell vertically The initial take off was without incident. As the and came to rest suspended in the trees with the tow plane and glider started the climb through nose of the glider touching the ground. Both pilots 100 feet the tow plane started to experience a were transported to hospital, and later released. loss of power. The tow continued however at a One of the occupant sustained minor injuries. significant loss of rate of climb. The gliding instructor radioed the tow plane pilot to ask if everything was “OK”. The tow plane pilot responded that things were not “OK”. The Launch Control Officer then radioed the glider pilot advising them to release when they felt it was safe to do so. Photo: DND Photo: Photo: DND Photo:

38 Flight Comment — Issue 3, 2015 TYPE: Bell 206B3 Jet Ranger LOCATION: Portage la Prairie, MB DATE: 6 May 2015

he accident aircraft, a Bell 206B3 Jet Ranger raised the collective in an attempt to reduce the The helicopter suffered serious damage to the tail with civilian registration C-FTHA and rate of descent and extend the glide. However boom and numerous components surrounding the T military designation CH139301, was a the rate at which engine power seemed to come main rotor transmission as a result of low rotor speed training helicopter operated by 3 Canadian Forces on was much slower than expected. and a hard landing. The crew was not injured. Flying Training School in Portage la Prairie, MB. The crew of two, a qualified flying instructor (QFI) With the helicopter’s main rotor speed being low The investigation is focusing on the engine with a student pilot (SP), was flying NAV 1 as and feeling vibrations with associated unusual response during the overshoot, and on human part of the Phase III basic helicopter course. sounds, it became apparent that an overshoot and organizational factors. was not going to be possible. The QFI flared and During the return to base following completion used what energy remained in the rotor to settle of the navigation portion of the mission, the the helicopter onto the ground just past a QFI gave the SP an unexpected simulated engine shallow depression. The helicopter landed with failure scenario. The QFI reduced the throttle to considerable forward speed and skidded forward idle to simulate the engine failure and advised for approximately 200 feet past the initial point the SP of the simulated emergency. The SP of contact. reduced the collective to enter autorotation while initiating a right 170º turn to manoeuvre into wind and towards an identified landing zone. He completed all required actions while establishing the aircraft on final approach to the landing zone. Once the exercise was completed and the QFI satisfied with the SP’s performance, the QFI took control to initiate an overshoot at approximately 250’ above ground level (AGL). Being closer to the ground, the QFI had now identified obstacles; DND Photo: namely a power line and uneven ground. At the same time as slowly applying power, the QFI Photo: DND Photo:

Issue 3, 2015 — Flight Comment 39 EpilogueEpilogue TYPE: CH149 Cormorant LOCATION: Bass River, Five Islands Provincial Park, NS DATE: 14 November 2013

he training scenario, near Bass River in The investigation focussed on the phenomenon Five Islands Provincial Park, NS, involved known as rollout, in which the rescue harness T hoisting two Search and Rescue Technicians connecting D-ring can misalign with the hoist (SAR Techs) and a rescue basket into and out of hook and allow the D-ring to disconnect. A Flight a wooded confined area while the helicopter Safety Flash bulletin was immediately sent to all remained in a 120 foot high hover. After the Royal Canadian Air Force hoist users to identify SAR Techs were lowered and some practice this hazard. manoeuvres were conducted using the rescue basket, the first SAR Tech and the rescue basket Preventive measures included changes to SAR were hoisted back on board the helicopter. Tech training, amended hoisting procedures and evaluation of a self-locking gate for the hoisting In preparation for being hoisted up, the second hook. SAR Tech stowed the rescue basket guide rope and verified that the helicopter was directly overhead before he attached the hoist hook to his harness and signalled to the Flight Engineer (FE) in the helicopter that he was ready. The FE then took up the slack in the hoist cable and began to raise the second SAR Tech. Seconds

later, the SAR Tech fell to the ground and landed DND Photo: flat on his back. Shortly after, the SAR Tech stood up and indicated to the FE that he was not injured. The FE reeled in the hoist hook and then brought the SAR Tech up using the back-up hoist. After returning to a staging area, the crew decided to terminate the training mission. Photo: DND Photo:

40 Flight Comment — Issue 3, 2015 EpilogueEpilogue TYPE: CC130608 Super Hercules LOCATION: Resolute Bay, NU DATE: 18 March 2015

he accident aircraft was a Lockheed the CYRB radio operator that Hercules and After considering the predicament and Martin CC130J Super Hercules transport Boeing 737 aircraft had previously taxied to confirming that the wingtip was clear of T aircraft operated by 436 Transport that location on the airfield, the First Officer the storage shed, the AC elected to continue Squadron out of 8 Wing, Trenton, Ontario (ON). (FO), who was the Pilot Flying (PF) and taxiing to the Polar Shelf apron where the The crew were flying a mission to Canada’s far occupying the left seat for this leg of the aircraft was parked and the engines shut north in support of Operation NOREX – an mission, proceeded to steer the Hercules down. A preliminary assessment was conducted exercise aimed at confirming the military’s northbound on Bravo taxiway. revealing considerable damage to the outer ability to operate in the northern environment. two feet of the left wingtip. Following this, The mission was transporting personnel, Having identified obstacles on the left hand the crew unloaded their passengers and equipment and supplies. side consisting of light poles and a storage cargo, terminating the mission. shed, the Aircraft Commander (AC) directed The accident aircraft with a crew of four that the FO taxi on the right side of the A full assessment of the damage revealed carried five pallets and twenty one passengers taxiway. While taxiing, the radio operator serious damage (C-Category) to the outer from 8 Wing, Trenton, ON to Resolute Bay, called to report that he believed the aircraft two feet of the left wing. The Preventive Nunavut (NU). The flight to Resolute Bay airfield had struck a light post. The FO then looked Measures focussed on task prioritization, (CYRB) on 18 March 2015 was uneventful and out at the left wingtip to see it make contact communication, training and correction of Hercules CC130608 made a successful landing with the storage shed (a second object) and routine deviations from standard procedures. on runway 35T in good weather conditions at the aircraft was brought to a stop. 11:01 local time. With only one mid-field taxiway to exit the runway, the crew backtracked in a southerly direction and exited westbound on Alpha taxiway. The CYRB radio operator directed the crew to park on the northern Polar Shelf apron due to a CC177 Globemaster III which occupied the better portion of the main apron and was scheduled to depart within two hours. Approaching Bravo taxiway which leads to the Polar Shelf apron, the crew asked the CYRB radio operator to confirm the feasibility of taxiing a Hercules aircraft to that location on

the airfield. After receiving confirmation from DND Photo: Photo: DND DND Photo:

Issue 3, 2015 — Flight Comment 41